Cycle 1
Health 2025-06-06 · Fire 2025-06-06
3 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mccordsville, IN
Majestic Care Of Mccordsville
4-star overall rating with 4-star inspections with 3 recent health deficiencies
7476 W Lane Rd, Mccordsville, IN
(317) 335-2159
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
35
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Majestic Care
Operator or chain grouping
Approved since
1995-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.22
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,413
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.36
Baseline 86.79% · Performance 62.86% · Measure score 3.36 · Achievement 0 · Improvement 3.36
Adjusted total nurse staffing
0
Performance 3.09 hours · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.44% |
8.2%
3.8 pts worse
|
Numerator 2 · Denominator 45 |
| Staff flu vaccination coverage | 3.7% |
42%
38.3 pts worse
|
Numerator 3 · Denominator 81 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.8%
1 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 41.3% |
24.6%
16.7 pts worse
|
11.4%
29.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.8% · Q2 46.4% · Q3 36.0% · Q4 37.0% · 4Q avg 41.3% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
5.6%
2.1 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 14.8% · Q3 0.0% · Q4 7.7% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 44.3% |
23.5%
20.8 pts worse
|
19.6%
24.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 48.1% · Q3 42.3% · Q4 48.1% · 4Q avg 44.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
14.8%
0.1 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.5% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.5% |
13.3%
5.8 pts better
|
16.3%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
11.7%
6.7 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 4.0% · Q4 8.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.4%
0.3 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
24.2%
5.5 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 30.0% · Q3 33.9% · Q4 32.2% · 4Q avg 29.7% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
4.1%
0.7 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.0% · Q3 4.9% · Q4 4.5% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.4% |
81.6%
10.2 pts worse
|
81.7%
10.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 75.8% · 4Q avg 71.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.3%
1.1 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-24 · Fire 2024-05-24
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-28 · Fire 2023-04-28
9 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-06-06
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-06
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-06-20
F · Potential for more than minimal harm
2024-05-24
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-06-07
E · Potential for more than minimal harm
2024-05-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-07
D · Potential for more than minimal harm
2023-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-04-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-28
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-28
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-04-28
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-05-09
Penalties and ownership
What sits behind the stars
Ownership
Hancock Regional Hospital
5% Or Greater Direct Ownership Interest · Organization
Alexander, James
Operational/Managerial Control · Individual
Bond, Maria
Corporate Director · Individual
Clark, Timothy
Corporate Director · Individual
Collins, Katlyn
Operational/Managerial Control · Individual
Daugherty, Joshua
Corporate Director · Individual
Felker, Dean
Corporate Director · Individual
Joyner, Sara
Corporate Director · Individual
Long, Steven
Operational/Managerial Control · Individual
Long, Steven
Corporate Officer · Individual
Ltc Consulting Services LLC
Operational/Managerial Control · Organization
Majestic Care Of Mccordsville, LLC
Operational/Managerial Control · Organization
Majestic Management LLC
Operational/Managerial Control · Organization
Pruitt, Paul
Operational/Managerial Control · Individual
Radadiya, Pragneshkumar
Operational/Managerial Control · Individual
Rewa, Angela
Operational/Managerial Control · Individual
Russell, Robert
Operational/Managerial Control · Individual
Shatrov, Anzhelika
Operational/Managerial Control · Individual
Wilson, Roy
Corporate Director · Individual
Wolfe, Eric
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Westminster Village North
Indianapolis, IN
1-star overall rating with 1-star inspections with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Harrison Terrace
Indianapolis, IN
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Castleton Health Care Center
Indianapolis, IN
1-star overall rating with 1-star inspections with 20 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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